Assessment of Osteonecrosis in the Presence of Instrumentation for Femoral Neck Fracture Using Contrast-Enhanced MAVRIC Sequence



Evaluating postoperative femoral neck facture (FNF) with metal fixation hardware is commonly performed using radiographs. MRI has greater sensitivity and specificity to evaluate osteonecrosis (ON) but is often challenging due to the image distortion caused by metallic hardware.


The aim of this study is to compare fast spin-echo (FSE) and multi-acquisition variable-resonance image combination (MAVRIC) sequences in assessing ON following metallic fixation of FNF and determining feasibility of semi-quantitative perfusion using MAVRIC.


Radiography and MRI were performed at 3 and 12 months postoperatively, using FSE and pre- and post-gadolinium contrast MAVRIC sequences in 21 FNF patients. The presence and volume of ON were recorded. Signal intensity (SI) enhancement was measured on the MAVRIC sequences within the center and rim of ON; with the ilium and femoral diaphysis as controls. The detection rate of ON between MAVRIC and FSE images was evaluated as the difference of percent enhancement across the defined regions of interest.


ON was detected in 0% of radiographs, in 67% of FSE, and in 76% of MAVRIC images at 3 months follow-up, with similar results at 12 months. MAVRIC images had larger ON volume than FSE images at both time points. A significant percentage SI enhancement was only detected in the ON rim.


Radiographs could not detect ON following metallic fixation of FNF. MAVRIC is more sensitive than FSE for determining the volume of ON. SI measurements using MAVRIC may provide an indirect assessment of perfusion.

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  1. 1.

    Ai ZS, Gao YS, Sun Y, Liu Y, Zhang CQ, Jiang CH. Logistic regression analysis of factors associated with avascular necrosis of the femoral head following femoral neck fractures in middle-aged and elderly patients. J Orthop Sci. 2013; 18(2): 271-276.

    Article  PubMed  Google Scholar 

  2. 2.

    Arnoldi CC, Lemperg RK. Fracture of the femoral neck. II. Relative importance of primary vascular damage and surgical procedure for the development of necrosis of the femoral head. Clin Orthop Relat Res. 1977; 129(129): 217-222.

    Article  PubMed  Google Scholar 

  3. 3.

    Bassett LW, Gold RH, Reicher M, Bennett LR, Tooke SM. Magnetic resonance imaging in the early diagnosis of ischemic necrosis of the femoral head. Preliminary results. Clin Orthop Relat Res. 1987; 214: 237-248.

    PubMed  Google Scholar 

  4. 4.

    Cobb AG, Gibson PH. Screw fixation of subcapital fractures of the femur--a better method of treatment? Injury. 1986; 17(4): 259-264.

    Article  CAS  PubMed  Google Scholar 

  5. 5.

    Donati OF, Zanetti M, Nagy L, Bode B, Schweizer A, Pfirrmann CW. Is dynamic gadolinium enhancement needed in MR imaging for the preoperative assessment of scaphoidal viability in patients with scaphoid nonunion? Radiology. 2011; 260(3): 808-816.

    Article  PubMed  Google Scholar 

  6. 6.

    Dyke JP, Lazaro LE, Hettrich CM, Hentel KD, Helfet DL, Lorich DG. Regional analysis of femoral head perfusion following displaced fractures of the femoral neck. J Magn Reson Imaging. 2013; 41(2): 550-554.

    Article  PubMed  Google Scholar 

  7. 7.

    Ehlinger M, Moser T, Adam P, et al. Early prediction of femoral head avascular necrosis following neck fracture. Orthop Traumatol Surg Res. 2011; 97(1): 79-88.

    Article  CAS  PubMed  Google Scholar 

  8. 8.

    Garden RS. Stability and Union in Subcapital Fractures of the Femur. J Bone Joint Surg Br. 1964; 46: 630-647.

    CAS  PubMed  Google Scholar 

  9. 9.

    Gatehouse PD, Bydder GM. Magnetic resonance imaging of short T2 components in tissue. Clin Radiol. 2003; 58(1): 1-19.

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Gribbestad IS, Gjesdal KI, Nilsen G, Lundgren S, Hjelsteun MHB, Jackson A. An Introduction to Dynamic Contrast-Enhanced MRI in Oncology. Medical Radiology. Berlin/Heidelberg: Springer; 2005.

    Google Scholar 

  11. 11.

    Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int. 1997; 7(5): 407-413.

    Article  CAS  PubMed  Google Scholar 

  12. 12.

    Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969; 51(4): 737-755.

    CAS  PubMed  Google Scholar 

  13. 13.

    Hayter CL, Koff MF, Shah P, Koch KM, Miller TT, Potter HG. MRI after arthroplasty: comparison of MAVRIC and conventional fast spin-echo techniques. Am J Roentgenol. 2011; 197(3): W405-W411.

    Article  Google Scholar 

  14. 14.

    Hayter CL, Koff MF, Potter HG. Magnetic resonance imaging of the postoperative hip. J Magn Reson Imaging. 2012; 35(5): 1013-1025.

    Article  PubMed  Google Scholar 

  15. 15.

    Hernigou P, Poignard A, Nogier A, Manicom O. Fate of very small asymptomatic stage-I osteonecrotic lesions of the hip. J Bone Joint Surg Am. 2004; 86-A(12): 2589-2593.

    CAS  PubMed  Google Scholar 

  16. 16.

    Jakob M, Rosso R, Weller K, Babst R, Regazzoni P. Avascular necrosis of the femoral head after open reduction and internal fixation of femoral neck fractures: an inevitable complication? Swiss Surg. 1999; 5(6): 257-264.

    Article  CAS  PubMed  Google Scholar 

  17. 17.

    Kannus P, Parkkari J, Sievanen H, Heinonen A, Vuori I, Jarvinen M. Epidemiology of hip fractures. Bone. 1996; 18(1 Suppl): 57S-63S.

    Article  CAS  PubMed  Google Scholar 

  18. 18.

    Kaushik A, Sankaran B, Varghese M. To study the role of dynamic magnetic resonance imaging in assessing the femoral head vascularity in intracapsular femoral neck fractures. Eur J Radiol. 2010; 75(3): 364-375.

    Article  PubMed  Google Scholar 

  19. 19.

    Khurana JS. Bone Pathology. 2nd ed. New York: Humana Press; 2009.

    Google Scholar 

  20. 20.

    Koch KM, Hargreaves BA, Pauly KB, Chen W, Gold GE, King KF. Magnetic resonance imaging near metal implants. J Magn Reson Imaging. 2010; 32(4): 773-787.

    Article  CAS  PubMed  Google Scholar 

  21. 21.

    Koch KM, Brau AC, Chen W, et al. Imaging near metal with a MAVRIC-SEMAC hybrid. Magn Reson Med. 2011; 65(1): 71-82.

    Article  CAS  PubMed  Google Scholar 

  22. 22.

    Koff MF, Shah P, Koch KM, Potter HG. Quantifying image distortion of orthopedic materials in magnetic resonance imaging. J Magn Reson Imaging. 2013; 38(3): 1083-1091.

    Article  Google Scholar 

  23. 23.

    Lang P, Jergesen HE, Moseley ME, Block JE, Chafetz NI, Genant HK. Avascular necrosis of the femoral head: high-field-strength MR imaging with histologic correlation. Radiology. 1988; 169(2): 517-524.

    Article  CAS  PubMed  Google Scholar 

  24. 24.

    Lavernia CJ, Sierra RJ, Grieco FR. Osteonecrosis of the femoral head. J Am Acad Orthop Surg. 1999; 7(4): 250-261.

    CAS  PubMed  Google Scholar 

  25. 25.

    Lieberman JR, Berry DJ, Mont MA, et al. Osteonecrosis of the hip: management in the 21st century. Instr Course Lect. 2003; 52: 337-355.

    PubMed  Google Scholar 

  26. 26.

    Lofthus CM, Osnes EK, Falch JA, et al. Epidemiology of hip fractures in Oslo. Norway Bone. 2001; 29(5): 413-418.

    Article  CAS  PubMed  Google Scholar 

  27. 27.

    Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg Am. 1994; 76(1): 15-25.

    CAS  PubMed  Google Scholar 

  28. 28.

    Min BW, Kim SJ. Avascular necrosis of the femoral head after osteosynthesis of femoral neck fracture. Orthopedics. 2011; 34(5): 349.

    PubMed  Google Scholar 

  29. 29.

    Nikolopoulos KE, Papadakis SA, Kateros KT, et al. Long-term outcome of patients with avascular necrosis, after internal fixation of femoral neck fractures. Injury. 2003; 34(7): 525-528.

    Article  CAS  PubMed  Google Scholar 

  30. 30.

    Sakai T, Sugano N, Nishii T, Haraguchi K, Ochi T, Ohzono K. MR findings of necrotic lesions and the extralesional area of osteonecrosis of the femoral head. Skeletal Radiol. 2000; 29(3): 133-141.

    Article  CAS  PubMed  Google Scholar 

  31. 31.

    Sansone M, Aprile F, Fusco R, Petrillo M, Petrillo A, Siani A et al. A study on reference based time intensity curves quantification in DCE-MRI monitoring of rectal cancer. World Congress on Medical Physics and Biomedical Engineering; Sept 7-12; Munich, Germany: IFMBE Proceedings; 2009: 38-41.

  32. 32.

    Sugano N, Masuhara K, Nakamura N, Ochi T, Hirooka A, Hayami Y. MRI of early osteonecrosis of the femoral head after transcervical fracture. J Bone Joint Surg Br. 1996; 78(2): 253-257.

    CAS  PubMed  Google Scholar 

  33. 33.

    Takatori Y, Kokubo T, Ninomiya S, Nakamura S, Morimoto S, Kusaba I. Avascular necrosis of the femoral head. Natural history and magnetic resonance imaging. J Bone Joint Surg Br. 1993; 75(2): 217-221.

    CAS  PubMed  Google Scholar 

  34. 34.

    Totty WG, Murphy WA, Ganz WI, Kumar B, Daum WJ, Siegel BA. Magnetic resonance imaging of the normal and ischemic femoral head. AJR Am J Roentgenol. 1984; 143(6): 1273-1280. doi:10.2214/ajr.143.6.1273.

    Article  CAS  PubMed  Google Scholar 

  35. 35.

    Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992; 30(6): 473-483.

    Article  PubMed  Google Scholar 

  36. 36.

    Zalavras CG, Lieberman JR. Osteonecrosis of the femoral head: evaluation and treatment. J Am Acad Orthop Surg. 2014; 22(7): 455-464.

    Article  PubMed  Google Scholar 

  37. 37.

    Zar JH. Biostatistical Analysis. Englewood Cliffs: Prentice Hall; 1984.

    Google Scholar 

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The authors would like to thank Joo Jung RT (MR) for his assistance in performing this study. This project has been supported by a grant from the AO Research Fund of the AO Foundation (AO Research Grant F-09-6H).


Conflict of Interest

Jonathan P. Dyke, PhD, Lionel E. Lazaro, MD, Parina Shah, MS and Dean G. Lorich, MD have declared that they have no conflict of interest. Nadja A. Farshad-Amacker, MD reports grants from AO Research Fund during the study. Matthew F. Koff, PhD reports other from GE Healthcare during the study. Hollis G. Potter, MD reports other from GE Healthcare during the study.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

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Informed consent was obtained from all patients for being included in the study.

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Correspondence to Matthew F. Koff PhD.

Additional information

Level of Evidence: II: Development of diagnostic criteria on consecutive patients (with universally applied reference “gold” standard)

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Farshad-Amacker, N.A., Koff, M.F., Dyke, J.P. et al. Assessment of Osteonecrosis in the Presence of Instrumentation for Femoral Neck Fracture Using Contrast-Enhanced MAVRIC Sequence. HSS Jrnl 12, 51–58 (2016).

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  • osteonecrosis
  • avascular necrosis
  • femoral neck fracture
  • metal artifact